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S2E3 - The Take-Home Side of Pain Management
10 Plays1 hour ago
What happens after the patient goes home? In this episode, our trio of veterinary anesthesiologists dives into oral pain medications, and the realities of keeping pets comfortable outside the hospital. We discuss common go-home medications, multimodal pain strategies, compliance challenges, side effects, and how treatment plans are tailored to different patients and conditions. Practical, approachable, and full of real-world insights, this episode focuses on the part of pain management owners deal with every day.
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Transcript
Intro
Introduction and Topic Selection
00:00:38
Gianluca Bini
All right. So whose topic is tonight, Ryan?
00:00:43
Ryan Bailey
Mm-hmm.
00:00:44
Gianluca Bini
Nice. What you got?
00:00:48
Ryan Bailey
Well, so I'll be honest, the inspiration did not come to me the last, like, I don't know, year or how long it's been since I've had to choose the topic. So I solicited some advice from friends. And given that, I thought little behind the scenes for the fucking viewers at home, were supposed to record yesterday, but some extenuating circumstances arose and we did not.
00:01:12
Ryan Bailey
But yesterday I was busy with a bunch of projects, so I did not have a chance to come up with all the normal litany of crap that I do in regards to these
Oral Analgesic Options for Pets
00:01:22
Ryan Bailey
topics. So my friend, Gabby Escalante, also an anesthesiologist, gave me a great topic to discuss that I felt immediately stuck with me and the amount of energy it took me to come up with the ideas.
00:01:36
Ryan Bailey
you know, was low because they automatically just popped in my head versus some other ideas I was given that would definitely need to do more research on.
00:01:36
Gianluca Bini
OK.
00:01:46
Ryan Bailey
So, all right, are you ready?
00:01:46
Annatasha
All right. Yeah.
00:01:49
Gianluca Bini
So what you got?
00:01:52
Ryan Bailey
I want to talk about oral analgesic options specifically for dogs and cats. And we don't have to limit it to orals, but I want to focus on kind of the outpatient analgesic options that we talk about Maybe what we're recommending, what works, what doesn't work. Maybe we'll talk about some like old favorites that are new again all of the sudden.
00:02:16
Ryan Bailey
we'll talk about some hot topics that people fucking hate. I just felt like it's a good... don't really... This is an area where we're asked a lot of questions. And because of some of the workflow issues that we experience in our jobs, you know, we
Challenges with NSAIDs in Pets
00:02:32
Ryan Bailey
don't... We are kind of advisors, but not always primary decision makers on that. So, yeah, that's my long-winded windup.
00:02:45
Ryan Bailey
So what do you
00:02:46
Gianluca Bini
Well, and Zahid.
00:02:48
Ryan Bailey
got? Great.
00:02:48
Gianluca Bini
I got an easy one. Yeah.
00:02:49
Annatasha
First, I want to say, hate this question.
00:02:54
Ryan Bailey
I know. As soon as she gave it to me, was like, fuck. Like, it's such thing.
00:02:58
Annatasha
It's the right question to ask because we need to address things where we struggle and where we hate because that's really where you need bolster knowledge. And the reason, just so everyone knows I hate this question, is because...
00:03:10
Annatasha
It's just very challenging because there aren't a lot of options and not all the options are as efficacious as I think we want them to be.
00:03:12
Gianluca Bini
Thank you.
00:03:29
Annatasha
So it's nice to discuss it, and I think hopefully it will be helpful to the four people listening. But yeah, it's one of those things that kind of like, it's almost a little bit like to like oral sedation at home for like fractious patients. Like kind of makes you want put your head down and give up a little just because...
00:03:48
Gianluca Bini
Yeah.
00:03:54
Annatasha
And like Beanie says, like NSAIDs, but I mean, I find even still like NSAIDs upregulate people so unreasonably sometimes and they will just strike it off the list at like the tiniest little like ridiculous reason.
00:04:08
Annatasha
And it's such an important part of the spectrum of care. So... Yeah, good question. Good and bad question at the same time. Good needs to be discussed. Bad, it's a challenging thing to discuss. Yeah.
00:04:23
Annatasha
Beanie, you were saying NSAIDs before I casually interrupted as usual.
00:04:24
Gianluca Bini
All right, let's cut to the chase. Let's cut to the chase, right? What options do we have, right? So, NZ is probably one of the mainstay, right?
00:04:35
Gianluca Bini
I think, as you say, yes, we do have a lot of, you know, there is a lot of times, like, reasons not to give NZ. Sometimes it's probably... We may be too cautious, right?
00:04:49
Gianluca Bini
Like sometimes. So, yeah. I mean, so in which instances do you think NSAID is a no-no, right?
00:05:02
Gianluca Bini
Usually kidney, liver disease, right? Usually those are the two main reasons.
00:05:07
Annatasha
mean, honestly, Beanie, I'm not, I don't, I feel like everyone tars those cases a lot with the same brush. And I feel like there's, particularly for us, there's more nuance to that. Do it, you know, it's not just liver, because I think we need to talk a little bit about what that implies.
00:05:17
Gianluca Bini
Where? Okay.
00:05:22
Annatasha
Like, is it, is there sense that there's been some sort of liver irritation or is it liver dysfunction? And if so, on like, when, when is the scale appropriate? And it's the same thing with like, you know,
00:05:33
Annatasha
GI signs and and and you know if I have like a 19 year old cat who has like chronic renal insufficiency but is like an agonizing pain for a variety of different reasons am I going to withhold a medicamp no right because it's a question of quality of life over like worrying about adverse effects so I hate when people talk about NSAIDs in that way like I don't give it if it's liver kidney or GI and then we make
00:05:51
Gianluca Bini
so
00:05:58
Annatasha
ridiculous comments about things like platelet aggregation and really does, this is a specific area where I think we need to do much better because the discussion really does need to titrate itself down to being more specific. And that's, it's very similar, for example, like dexmed and cardiac disease, like, you know, like don't give dexmed you have cardiac disease. And it's like, oh, shut up.
00:06:17
Annatasha
And that's exactly the same thing that I feel about the NSAIDs too. Like you have to think critically through what is appropriate and what's in the best interest of the patient more so than I find, for example, like so many people are like, don't want do that because I don't want get in trouble. And I'm like, your job is to look after the patient, not after your own ass. So do a better job. So.
00:06:36
Gianluca Bini
I mean, both technically, right? Technically it's both. But so, yeah, no, I agree with you. And I tend to think, so I'm way more...
00:06:51
Gianluca Bini
I rely a lot on sometimes on what actually happened during anesthesia. If I have a patient that's been hypodensive for a while, tend to delay maybe the handset the night rather than giving it immediately post-op.
00:07:08
Gianluca Bini
I know that some clinics, they tend to give it pre-op, which I think is kind of a dangerous game to play.
00:07:16
Annatasha
I mean, this is a whole other podcast.
00:07:17
Ryan Bailey
Oh.
00:07:17
Annatasha
Like when should you give your NSAID? And I agree with you, Beanie. Like I generally, I don't give it before anesthesia if I think that there's a reasonable potential for to be a complication and I have been burned.
00:07:30
Annatasha
so many times for acute bleeds that were unexpected or for like ridiculous cases where you totally healthy patient that has like refractory hypotension for the whole anesthesia and you're like why is this happening know and you're just like so unless you're like kind of what I would call like out of the woods like for example you're past the point where hemorrhage is a huge risk you know or you know we're at closure or things like that okay fine go ahead but I feel like every 10 years we also it's like give the NSAID at the start, give the NSAID at the end, give the NSAID at the start, give the NSAID at the end.
00:07:32
Gianluca Bini
this
00:07:59
Annatasha
But like I said, I've been, I've definitely had my ass handed to me by things like severing of the popliteal artery during a TPLO. And now we have an NSAID on board and the criticalist is looking at you like, you know, you've recently had a lobotomy and you're like, well, I mean, that's not supposed to happen, you know,
00:08:17
Gianluca Bini
you know i think i think you know in terms of moa pre-op makes sense right but the the risk is so high that like i think that i rather it safe and just give it post-op or, know, a closure you know, when you're about to be done. You know, I think the intra-hop, we can manage pain much better with many other things that you don't necessarily need the hands-aids, right?
00:08:47
Annatasha
Okay.
00:08:47
Gianluca Bini
Post-op, you're way more limited. So, you know. But besides that,
00:08:52
Annatasha
Bailey, when do you give your NSAID? When do you give your NSAID?
00:08:56
Gianluca Bini
me?
Personal Experiences with NSAIDs
00:08:57
Annatasha
Bailey.
00:08:58
Gianluca Bini
Oh.
00:08:59
Annatasha
Beanie and I already agreed, so we're just going to wait for you to say something Doppler.
00:09:02
Ryan Bailey
are you my pet are you my patient?
00:09:06
Annatasha
don't know.
00:09:08
Ryan Bailey
Because it differs, to be honest. It's because I don't have the evidence to support my wild ass theory. But, so my own personal cats who had dentals or whatever, they got NSAIDs the night before.
00:09:26
Ryan Bailey
They got it with like their Sirenia and their sedatives and they got their Anseor the night before.
00:09:34
Annatasha
Okay.
00:09:35
Ryan Bailey
And one of them had, So I think the one actually didn't get it the night before. I like scoured my house to find dose of Onsior, but I did not, or Robenococcin, whatever.
00:09:45
Ryan Bailey
I did not have an available dose for him. So he did not get.
00:09:49
Annatasha
Why did you serve like random like NSA just scattered through your house? You're just like bills, bills, on seor.
00:09:53
Ryan Bailey
Well,
00:09:55
Gianluca Bini
This
00:09:55
Annatasha
Like...
00:09:57
Ryan Bailey
I mean, just, you know, I make sure I have medications for my pets. So if they have to go to the clinic, I have some sedatives. So they're not assholes because one of them is a real, and I thought maybe I happened to have a dose from her dental procedure where, you know, she had some NSAIDs for post-op pain. and then I think actually when he, I will actually say when he went to the clinic, one of my requests was, well, before his anesthesia, was like, if you have oral on zero, can you give him a dose before we get started?
00:10:25
Ryan Bailey
and so that comes from like a, what John Luca said, the mechanism of action, we know going to be working like before the procedure starts. B, there was a older paper that showed patients who are on oral NSAIDs had like much lower pain scores no matter what pain medication plan they were administered during a TPLO procedure.
00:10:33
Gianluca Bini
Hmm.
00:10:48
Ryan Bailey
And so one of the journal club discussions we had on that paper was whether the oral encese has actually like helped with the pain they were experiencing. And so it didn't matter what pain options you chose, like HLK or epidural or whatever.
00:11:02
Ryan Bailey
And then there's, this is like where we're starting to really get out there is there's been couple, I'm just going to say controversial papers and discussions within and at our larger lecture series conferences, in which there has been question about the use of parenteral injectable NSAIDs and the rates of acute kidney injury that are reported.
00:11:33
Ryan Bailey
there's some speculation out there about, are we seeing the same rates with oral medications versus the parenteral medications.
00:11:42
Gianluca Bini
Gotcha.
00:11:43
Ryan Bailey
So all those reasons...
00:11:43
Annatasha
Well, what was the conclusion of that conversation? Because I'm curious to know.
00:11:48
Ryan Bailey
What's that?
00:11:49
Annatasha
What was the conclusion of that conversation?
00:11:50
Ryan Bailey
There is no conclusion. There is no conclusion at this time. The conclusion is more research needs to be done.
00:11:56
Gianluca Bini
Yeah, so that's useless.
00:11:56
Annatasha
Okay.
00:11:58
Ryan Bailey
What's that?
00:11:59
Gianluca Bini
So that's useless.
00:12:00
Annatasha
What the conversation? Okay.
00:12:02
Gianluca Bini
Yes, that's probably useless.
00:12:02
Ryan Bailey
I mean, you have to start somewhere once again.
00:12:04
Gianluca Bini
right, sure.
00:12:07
Ryan Bailey
So in my patient population, if they're on NSAIDs, great. If they give them orally, I'm not going to sweat it. If they have not gotten them orally and I need to decide, I'm going to recommend of an abundance of precaution based as far as I'm aware, actual evidence to support this claim that we all practice. I will administer them after anesthesia, assuming it all went well and we did not have experienced a hypotensive crisis.
00:12:35
Gianluca Bini
Yeah, I think that most of it comes from, you know, the increased potential risk of acute kidney injury. If you have the combination of hypotension, prolonged hypotension and, you know, NSA administration.
00:12:50
Gianluca Bini
Now,
00:12:53
Ryan Bailey
But is there evidence? Show me the evidence. I know the mechanism is there and I know the theory is there. I believe all of that, but show it
00:13:00
Gianluca Bini
No, no, I understand that. But like how many people in that math are actually looking for acute kidney injury, right? In humans, we do not send the people home till they pee after anesthesia, right?
00:13:16
Gianluca Bini
Like they wanna make sure you're not in that teneuric phase of AKI, which is the very first phase of AKI, right?
00:13:16
Ryan Bailey
What?
00:13:22
Gianluca Bini
In vet med, we ship the dog home or the cat home two hours afterwards, whether they peed or not, the owner is not instructed to even look for pee or for urination or not, right? Like half of the time, if you read the discharges, like nobody, I've,
00:13:39
Gianluca Bini
I can comfortably say that I've never seen anybody right on a fucking discharge monitor for urination. All right? Have you?
00:13:50
Gianluca Bini
No.
00:13:52
Ryan Bailey
I'm in agreement. I think there is...
00:13:55
Gianluca Bini
No. No,
00:13:56
Ryan Bailey
You're preaching the choir.
00:13:56
Annatasha
Let's just answer for each other. Have you seen it? No. Okay.
00:13:59
Gianluca Bini
I'm sorry. Anyway, so also, by the way,
00:14:03
Annatasha
This also, by the way, has nothing to do with oral medication. So we are doing a tip top job here.
00:14:08
Gianluca Bini
Oh yeah, we're totally diverging in a fucking rabbit hole as usual.
00:14:08
Ryan Bailey
Yeah.
00:14:12
Gianluca Bini
But basically, But that's the problem, right? So these studies are almost impossible to make in veterinary medicine. A, we're shifting a follow-up, right?
00:14:23
Gianluca Bini
Like, you know, somebody comes in, know, specialist sender, they do anesthetize that pet, they send it home.
00:14:33
Gianluca Bini
If six months later a year later, that pet has CKD, God knows,
00:14:38
Ryan Bailey
Right.
00:14:38
Gianluca Bini
right?
00:14:38
Ryan Bailey
Absolutely.
00:14:38
Gianluca Bini
Nobody follows up a year later or six months later. God knows. Also, we get blood work way less often. You know, our patients, right?
00:14:48
Gianluca Bini
Like, you know, maybe they came in, they had surgery, they go back home, they go to a regular vet, maybe like
00:14:51
Annatasha
Thank you.
00:14:56
Gianluca Bini
couple of months later, they do not get blood work till one or two years later down the road, right? Like, so the frequency that our pets get checked at, it's way lower than humans are.
00:15:08
Ryan Bailey
Yeah.
00:15:09
Gianluca Bini
And so all of this contributes to the fact that these studies are almost impossible to make.
00:15:15
Gianluca Bini
And that's why in 20 or 30 years or more of literature, there isn't one, because
00:15:19
Ryan Bailey
Yeah.
00:15:20
Annatasha
Well, I think we need to be careful because what I don't want to have happen is everyone starts checking blood work and then blaming us.
00:15:29
Annatasha
I don't need to hear about CKD six months down the road. And that also get tacked onto anesthesia's problem list. So, Of course.
00:15:35
Gianluca Bini
Sometimes it is. Like, why do you think all these cats out there have chronic kidney disease?
00:15:40
Ryan Bailey
Thank you. That's, I was like, and here's, here's, I'm going to jump in with my other crazy theory. reason cats all have CKD is because they're also fucking hypotensive under anesthesia and no one manages it correctly.
00:15:46
Annatasha
Yeah.
00:15:50
Gianluca Bini
Yeah, 100%.
00:15:52
Ryan Bailey
And they're all developing AKI multiple times at these stupid fucking dentals. And that's why you see all this CKD in cats.
00:15:59
Gianluca Bini
Well, wait.
00:16:00
Annatasha
You guys just did exactly what I told us not to do.
00:16:00
Gianluca Bini
Wait.
00:16:03
Annatasha
Not that you're wrong, but I was like, from a political standpoint, we really just shot ourselves in the foot, guys.
00:16:05
Gianluca Bini
So
00:16:09
Gianluca Bini
I think that more than the dendles, which I agree that sometimes it's...
00:16:14
Ryan Bailey
It's just the most common repeated anesthesia event for these patients.
00:16:17
Gianluca Bini
Gotcha. I think that most of the damage is made as pain neuter because those...
00:16:22
Ryan Bailey
Yeah, I think there's consistent damage though through time, but I do, do absolutely agree with you.
00:16:26
Gianluca Bini
How many...
00:16:27
Ryan Bailey
I think there's a major hit there. And then think there is additional subsequent hits in additional procedures because cats are just so, they're so frustrating.
00:16:36
Gianluca Bini
Sure. And let's make it clear if some pet owner is listening, this isn't a dendl where we're talking about people that do not monitor their patients appropriately or they do monitor them but not take the appropriate interventions.
00:16:46
Ryan Bailey
Yes. Right.
00:16:55
Ryan Bailey
Yeah, absolutely.
00:17:02
Ryan Bailey
Yes.
00:17:02
Annatasha
Yeah, to be clear, we're not talking about us three.
Anesthesia and Kidney Function Risks
00:17:11
Annatasha
Well, I live in hope that that is a true statement, but I definitely want to be like, it's not the three of us. Yeah.
00:17:18
Gianluca Bini
Okay. But, you know, I think that the major hit do really comes at, you know, spay and neuter with the excuse of being a relatively short procedure in the 20 to 30 minute range.
00:17:31
Ryan Bailey
In a healthy patient who has reserves.
00:17:32
Gianluca Bini
In a healthy patient, there is clinics out there that do not monitor blood pressure. And there is clinic that if they do monitor blood pressure, don't have a way to fix it.
00:17:44
Ryan Bailey
Yeah.
00:17:44
Gianluca Bini
Right.
00:17:44
Annatasha
Listen, there clinics out there who send pets home with comminuted fractures and no oral medication, so.
00:17:45
Gianluca Bini
And so that's it.
00:17:50
Ryan Bailey
And they may or may not be intubated because the evidence suggests that intubating a cat can lead to like higher likelihood of complication in a very old paper that still gets brought up.
00:17:56
Gianluca Bini
I mean, that's...
00:18:00
Annatasha
paper. One paper.
00:18:01
Annatasha
100%.
00:18:02
Ryan Bailey
That still gets dragged out from time to time.
00:18:02
Annatasha
I have to, yeah. Mm-hmm.
00:18:06
Gianluca Bini
Yeah. So long story short, there's people out there that do bunch of sketchy shit.
00:18:12
Gianluca Bini
And that's why a lot of the cats do suffer kidney damage.
00:18:16
Ryan Bailey
Like, like the people who fucking give their own cats at home their, you know, right around NSAIDs.
00:18:25
Gianluca Bini
And that's Ryan Bailey for you guys. anyway,
00:18:29
Ryan Bailey
So, Martel, when do you give your cat, your pets, when do you give your patients their NSAIDs and how do you manage that?
00:18:37
Ryan Bailey
Yeah. Oh,
00:18:39
Annatasha
I'm the same as Beanie. I like to clear the air, but you should also know that my cat has been on daily meloxicam for over three years to manage chronic DDG and OA.
00:18:40
Ryan Bailey
yeah.
00:18:49
Ryan Bailey
Exactly.
00:18:50
Annatasha
could not have more perfect renal values probably up until this afternoon, but that's for a whole other reason.
00:18:56
Annatasha
So, yeah, BW got diagnosed with carcinomatosis this afternoon.
00:18:57
Gianluca Bini
What
00:19:01
Gianluca Bini
the fuck?
00:19:01
Annatasha
So, yeah, it's okay.
00:19:03
Gianluca Bini
I'm sorry.
00:19:03
Ryan Bailey
that are happening.
00:19:07
Gianluca Bini
Is this brownie?
00:19:09
Annatasha
The one who swims, My swimmer.
00:19:10
Gianluca Bini
So brownie.
00:19:12
Annatasha
No, Brownie's fine. Brownie's just a diabetic and an asshole, but BW is the one who goes swimming and is on all the videos.
00:19:13
Gianluca Bini
Oh, brownie.
00:19:19
Annatasha
Yeah.
00:19:20
Gianluca Bini
Oh.
00:19:21
Annatasha
Yeah.
00:19:22
Gianluca Bini
Poor guy.
00:19:23
Annatasha
But anyway, so yeah, that cat had been on meloxicam for years on a daily dose just to manage like chronic degenerative joint disease. So, you know, I am not, and the other thing too is, here's a quick question about NSAIDs.
00:19:39
Annatasha
do you guys always perform blood work, for example, before you recommend or prescribe an NSAID?
00:19:45
Gianluca Bini
Well, usually because it's post-
00:19:46
Annatasha
Like, would you consider that standard of care or a best practice? Because I feel like it's a little old school in my opinion, but I don't know, like, where do you guys land?
00:19:56
Gianluca Bini
I don't think outpatients you need to, but like, you know, in terms of like, you know, probably our field of work, I think usually our patients do come in for a procedure and then they get prescribed an NSAID afterwards.
00:20:07
Gianluca Bini
So they do come in with blood work, not because of the NSAID, but because of the procedure. So like, you know, that's, that's,
00:20:12
Ryan Bailey
Mm-hmm.
00:20:17
Gianluca Bini
That's my answer there. I don't run a pain clinic, so I know if I would have her lean that way. don't know what you think, Ryan.
00:20:24
Ryan Bailey
Yeah, so I think in our surgical, in our patients undergoing anesthesia, I think it's a bit of a different story for sure.
00:20:25
Annatasha
Thank you.
00:20:31
Ryan Bailey
So think, yes, recommending blood work in those situations. I think from my opinion as a veterinarian, knowing the incidence of acute kidney injury in our pets and our ability to treat those patients with anxiety,
00:20:47
Ryan Bailey
what ends up becoming chronic kidney disease being somewhat limited, species dependent for sure. I think it behooves us to at least inform owners of the risks of this, the potential for risks of this drug.
00:21:04
Ryan Bailey
and inform them of the options to mitigate those risks and whether they want to go through with that is up to them as long as they have the informed consent. But I think it's in our best interest to provide what we think is best for the patient, taking into account all of those risks. So let's here's a good example, you have an old crunchy cat who has a little laceration and maybe want to prescribe an NSAID, but the owners don't want to do blood work.
00:21:37
Ryan Bailey
I think that when you have to weigh a little more heavily than young healthy cat who has a laceration and you want to prescribe an NSAID, I think you can be a little bit more liberal if the owners don't want to go forward with blood work, just kind of assuming little bit of risk in those two different populations. Now in a dog, I think general rule of thumb that I would follow is like, if they don't want to do it, it's probably okay go ahead with it.
00:22:06
Ryan Bailey
At the same time though, dogs who develop CKD don't have the same levels of, like, I don't think they have the same like survival that cats do because cats get CKD and then they live for fucking ever.
00:22:13
Annatasha
Thank
00:22:19
Ryan Bailey
But dogs that develop like kidney injury and CKD, like, time's ticking, you know? And so like, if you do contribute to that, like that is, that is not an insignificant thing in dogs. So I think that is, that's something to weigh for sure. So I don't, it's not to me cut and dry, but I do think we should be a little bit more liberal with our NSAID use personally.
00:22:47
Ryan Bailey
That's long-winded.
00:22:48
Gianluca Bini
so
00:22:53
Ryan Bailey
Oh yeah.
00:22:54
Annatasha
You know, and think that constantly running blood work, like it can be cost prohibitive. And also, you know, I'm not sure what the value is. My next question though, is like, how many times have you guys incurred in your clinical experience, like an actual case of AKI that you really felt was directly related to like that recent anesthesia in which you were involved?
00:23:16
Ryan Bailey
Okay.
00:23:16
Gianluca Bini
I, to be honest...
00:23:17
Ryan Bailey
I would have predicted it. before the patient even came out of the case. You know what I'm saying? It's like this hypotension that's intractable. The patient came in in septic shock that was not adequately resuscitated prior to anesthesia because of time slash, you know, the disease process.
00:23:35
Ryan Bailey
You know, it's like, I'm doing the best I can, but I'm sure I'm not going to prevent AKI in those cases.
00:23:37
Gianluca Bini
Yeah.
00:23:41
Gianluca Bini
Yeah. Yeah.
00:23:42
Annatasha
Okay. Yeah.
00:23:43
Ryan Bailey
So like,
00:23:43
Annatasha
I've only had one case however many years. And it was exactly that type scenario. Like, you know, you had to go, the patient wasn't optimized, you know, it wasn't stable, but it couldn't be stabilized without surgery.
00:23:56
Annatasha
And it went in already on sort of the cusp of AKI. And I was like, and it was, you know, a crappy anesthesia. And I was just grateful to get it off the table, but the criticalists and I knew like tomorrow, like we're gonna be managing AKI, but that's once out of over 10,000 cases. So my question is, are we too worried about AKI?
00:24:19
Gianluca Bini
But
00:24:24
Ryan Bailey
But at the same time, there are probably... a large amount patients are developing acute kidney injury that goes undetected because we're not looking for it. And it resolves because the kidney does have some residual, like some robustness that it can, have some, some cell death and not be, you know, a disaster.
00:24:46
Annatasha
What you think?
00:24:47
Gianluca Bini
I don't think we're too worried about it. I think we're, again, we're not looking for it. think that, you know, the extent of your case was probably worse than, you know, the, we're talking about AKI, but like in general, like it's not the whole kidney that gets damaged, right?
00:24:51
Annatasha
Okay.
00:25:04
Gianluca Bini
Like, you know, there is a portion of it that gets damaged.
00:25:07
Ryan Bailey
Yeah.
00:25:07
Gianluca Bini
Like it doesn't happen all, it's not a whole of nothing kind of thing, right? So I think that the extent of the AKI also matters, right? And probably the situation where you have a septic patient or something that is a plegic or whatnot, of course, the damage that will be done there is way different than... And again, I'm not condoning who doesn't measure blood pressure and does not fix blood pressure, but then the...
00:25:36
Gianluca Bini
you know, 15 or 20 minutes in an unholy cell decat that goes under anesthesia for a spay in the clinic is doing a shitty job at it. Okay. So like, that's not, it's probably a very different situation. Right.
00:25:51
Gianluca Bini
the extent of the AGI is going to be different too. one thing that I was, you know, going to mention is like,
00:26:02
Gianluca Bini
So we've been talking about NSAIDs the whole time. I think that some people also forget the steroids are a good option for analgesia, right?
Steroids vs. NSAIDs for Pain Management
00:26:13
Gianluca Bini
Like, know, there is patients that cannot get an NSAID, but you could use steroids, right?
00:26:18
Ryan Bailey
So, You are like, you're on it today. just want to say that. was already, first of all, I was like, we gotta move on. We gotta like have some final parts on NSAIDs here and we gotta get to the next topic.
00:26:30
Ryan Bailey
Cause we're gonna spend an hour on NSAIDs. And had I known we could have spent an hour on NSAIDs, I would have been a lot lazier. me be honest. But like, why?
00:26:38
Annatasha
Okay.
00:26:40
Ryan Bailey
Are we not using steroids? Like, why? Why? I could, like, used to offer them all the time in my previous shot and be like, oh, you don't think it can have an NSAID? Well, how do you feel about a dose of steroids? Or how do you feel about a short course of steroids? And I might as well have been like, let me get out the ax and murder the patient in front of you. Would that be okay? Would you be okay with me doing that? Like, I don't, I could not for the life of me figure out the aversion to using steroids, like a short course of a steroid, like a week or whatever.
00:27:13
Gianluca Bini
I think there is a lot of aversion on steroids, right? Like, you know, and people, I think that people sometimes, A, they mishandle steroids, like dosing, right?
00:27:21
Ryan Bailey
Right.
00:27:22
Gianluca Bini
They go with way higher doses than, they don't understand that the, you know, the analgesic dose is lower than ant-inflammatory dose, which is lower than the, you know, um, know,
00:27:24
Ryan Bailey
Yeah.
00:27:34
Annatasha
immunosuppressive,
00:27:35
Gianluca Bini
immunosuppressant dose, right? So like there is different dosing levels and there is different effects at different doses. So, and there is different side effects at different doses.
00:27:42
Ryan Bailey
Absolutely.
00:27:45
Gianluca Bini
So the side effects that you get at the immunosuppressant dose, it's way worse than what you can get at the anti-inflammatory and or the analgesic dose. So every time that people think about steroids, they think about, okay, delayed wound healing, you know, what sort of side effects?
00:28:01
Annatasha
PUPD,
00:28:03
Gianluca Bini
Yeah, PUPD or that stuff.
00:28:04
Annatasha
question for you guys about steroids then like i i mean steroids are monster analogies like in human anesthesia right like it is
00:28:12
Ryan Bailey
Steroids and insects, that's like a common thing for humans to go home on.
00:28:16
Annatasha
there's they're much more reticent about opioids than we are but question like you feel in terms of like the anti-inflammatory capacity of an NSAID versus a steroid which one do you think is more efficacious
00:28:20
Ryan Bailey
For good reason.
00:28:29
Gianluca Bini
or steroids.
00:28:31
Annatasha
Okay. Based on what?
00:28:33
Ryan Bailey
Yeah.
00:28:36
Annatasha
Dear gentlemen, based on what?
00:28:37
Ryan Bailey
Yeah, that's great question.
00:28:42
Gianluca Bini
Yeah.
00:28:42
Ryan Bailey
mean, at least the mechanism of action, for sure.
00:28:45
Gianluca Bini
Mechanism.
00:28:45
Ryan Bailey
It works higher up in the chain.
00:28:49
Gianluca Bini
Yeah. And I think it works on way more being an endogenous, you know, usually you do release your own steroids, right? Like, so I think that it had some way more.
00:29:00
Gianluca Bini
Correct.
00:29:03
Annatasha
So based on basically like clinical reasoning, but we really don't actually know the answer, do we?
00:29:10
Ryan Bailey
yeah would say that's a fair
00:29:11
Annatasha
I mean, I will say too, in the last couple of years, right? Like for example, if you're doing something where you have like concerns about airway inflammation. had a lot of long conversations about should we give the steroid or should we give the NSAID and which one is really more efficacious in terms of anti-inflammatory. There's some newer vets, newer specialists coming out who are really driving the NSAID conversation versus the very rigid old school mentality that the NSAID is really the more potent and anti-inflammatory. And Personally, I don't have the answer. And I've, I've done both. And sometimes I've done both together because it's been a real fucking shit day. But yeah, I, I don't think there is an answer unless I have completely missed the plot.
00:29:53
Ryan Bailey
The only caveat I want to put on what you just said, Bartel, though, is like, is that conversation coming from the like delayed wound healing, increased dehiscence kind of conversation, aversion to, like it's an aversion to steroids and choosing NSAIDs in that situation versus like, you know what I'm saying?
00:29:54
Annatasha
Which is possible. Which is possible.
00:30:13
Annatasha
I don't have an answer to that. And it's possible that maybe that was the background, that process. It's not been like the forefront of the dialogues that I've sometimes had.
00:30:18
Ryan Bailey
Yeah.
00:30:21
Annatasha
Like a lot of the surgeons I worked with in Singapore, like we always, we sort of sat there and it was like, well, which one is better?
00:30:21
Ryan Bailey
Oh, for sure.
00:30:23
Gianluca Bini
Yeah.
00:30:28
Annatasha
So which one should we give, right? And sometimes if we had a like low indice of like, you know, indices of risk, Maybe we erred on the side of the NSAID. If we were really confident that the Frenchie was completely going to have to end up like having a trach, we would err on the side of the steroid.
00:30:44
Annatasha
I've made, I've had that before where I've given the NSAID for something totally unrelated, like had a polytrauma once who then its entire neck swelled at extubation. And then the criticalist was furious because they couldn't give the steroid.
00:30:55
Annatasha
And I was just like, well, technically can give them both together, know, blah, blah, blah. But yeah, there, I don't think there is an answer and nobody really asks this question.
00:31:04
Gianluca Bini
Yeah, that's fair.
00:31:05
Ryan Bailey
How can you tell, though? I mean, like, just a silly...
00:31:08
Annatasha
Well, that's another thing. How do you quantify the degree of anti-inflammation? You can either stick a tube in its trachea or you can't.
00:31:15
Ryan Bailey
Right, for sure, for sure. Yeah, like, I... I never got a lot of buy-in on using steroids, and I never, like in the patients that I saw as primary, I never really had occasion to recommend switching to a steroid for those guys, just because most of them were osteosarcoma cases, and I felt an NSAID was the better choice for those guys, but I'm sure I was seeing a different kind of
00:31:43
Ryan Bailey
pain patient for a different kind of cancer, I feel like maybe I would have pushed for steroid in those situations.
00:31:50
Annatasha
Which is nice because you can give orally, right?
00:31:50
Ryan Bailey
Mm
00:31:52
Annatasha
Like you can send them home and steroids are cheap and cheerful. Now I do get that. I've had patients before that they have gone home on oral steroids and like, it's interesting because like their side effects are so marked, you know, like they just go from zero to just like, like just uncontrollable, like urination all around the house.
00:32:05
Ryan Bailey
hmm.
00:32:11
Annatasha
And the owners are like, look, like if this is the answer so that my dog has better longevity for the next month, then I'm just going to stop altogether. And so I don't know, I find, you know, we're sort of relaxed about the side effects associated with steroids.
00:32:24
Annatasha
And it's probably because they don't incur like something is potentially life threatening as like a duodenal perforation, theoretically.
00:32:24
Ryan Bailey
Yeah.
00:32:31
Annatasha
But, you know, I think from the point of view of the client and the client pet relationship, and how that's actually impacting the longevity in terms of the pet, I think we do need to maybe have a little bit more careful consideration about the steroid.
00:32:35
Gianluca Bini
Thank
00:32:46
Ryan Bailey
Yeah, and there also is an owner aversion to steroids at times because the side effects in humans on steroids can actually be quite severe. And so some humans are quite averse steroids.
00:32:53
Annatasha
Oh, yeah. They get rage. Yeah, they get the steroid rage. They can get incredibly, like, edematous. Like, it can be very challenging. had lot of friends who had to take steroids associated like, chemotherapeutics when they went through cancer treatment.
00:33:05
Annatasha
And, like, they reported that sometimes, like, the steroids were the harder one to endure, know, because, like, they couldn't sleep. Like, they, you know, like, it was just, like, they were just manic all the time from the steroids.
00:33:15
Annatasha
So, but, yeah.
00:33:16
Ryan Bailey
And we want that for their community.
00:33:16
Annatasha
So, oral meds. So, check on steroids. Check on NSAIDs. What else?
00:33:21
Gianluca Bini
How about Tramadol?
00:33:22
Ryan Bailey
Okay. How about...
00:33:25
Annatasha
How about Tramadol?
00:33:25
Ryan Bailey
What do
00:33:26
Annatasha
How about Tramadol?
00:33:29
Gianluca Bini
Right? I mean, I think there's people...
00:33:30
Ryan Bailey
you want to call crack at all?
00:33:30
Annatasha
Tramadol is probably, it's in the shithouse, right?
00:33:31
Ryan Bailey
Or...
00:33:34
Annatasha
And I feel like we've totally like tossed it out.
00:33:36
Ryan Bailey
For what species?
00:33:40
Ryan Bailey
I know you're fly athlete.
00:33:42
Annatasha
But I still think that it has its place. Do you guys agree?
00:33:50
Ryan Bailey
In the patient's eyes.
00:33:50
Annatasha
I mean, my opinion, Go for it, Bailey, go for it, sorry.
00:33:54
Ryan Bailey
No, no.
00:33:54
Gianluca Bini
for it.
00:33:56
Ryan Bailey
I like how you asked the question and then you started to answer your own question before you gave us. Usually I just notice kind of a give and a take with you. You're like, I'm going to give my long-winded question about this and then let you go into it.
00:34:11
Ryan Bailey
And you just had so much to say you couldn't hold back. So knock out.
00:34:14
Annatasha
I mean, to be fair, earlier, John Luca did ask you a question and then answer on your behalf. At least in this case, I just answered my own.
00:34:24
Gianluca Bini
Oh my goodness, you guys.
00:34:27
Annatasha
I don't know, Tramadol, what do you think? Like, I mean, cats, for example, how you feel about Tramadol and cats? Because they're a lot more interesting, in my opinion, than dogs.
00:34:37
Ryan Bailey
thumbs up. Double thumbs up in fact. I mean, the evidence is there that it works if you get into them.
00:34:42
Annatasha
Can you get the cats in the cat?
00:34:46
Ryan Bailey
But like, yeah.
00:34:46
Annatasha
That's the thing.
00:34:47
Annatasha
Can you get it in the cat? Because Tramadol tastes butt.
00:34:50
Ryan Bailey
I mean, you can use like a pill pocket or you can get it compounded or there's the little tiny tabs or whatever. Although, although like I have some really strong feelings about cats and like,
00:35:02
Ryan Bailey
I mean, management options. I know, like, a shock. Bailey has weird opinions on cats. But, like, for cats, like, oral medication, fucking, why are you orally medicating your cat? There's so few, there's so many more options for cats of drugs you can give them that have prolonged action that don't need to be administered, you know, by mouth.
00:35:24
Annatasha
Such as?
00:35:24
Gianluca Bini
You're talking about Fendonit patches?
00:35:25
Annatasha
How
00:35:27
Ryan Bailey
No, no.
00:35:29
Annatasha
about a lidocaine pack?
00:35:33
Ryan Bailey
I mean, you got Zorbium, you got sustained release buprenorphine.
00:35:37
Gianluca Bini
No, no, no, no, no. Let's rewind. So let's talk about Fendonit patches, Ryan.
00:35:46
Annatasha
Technically not oral, so not really on the purview of tonight's conversation.
Topical Pain Management Options
00:35:51
Ryan Bailey
it was, I expanded it.
00:35:53
Ryan Bailey
I said it is outpatient analgesic options.
00:35:57
Annatasha
Oh, okay, okay. Sorry, I wasn't listening as usual because I don't care.
00:36:01
Ryan Bailey
Sucking.
00:36:05
Gianluca Bini
So what's your thought on Fendonet patch? Because that's a long-term analgesic option, really.
00:36:10
Ryan Bailey
For sure. For sure. I mean, from clinical experience from my understanding of the literature, they are trash they should generally be recommended patients to them is my opinion the absorption is erratic if at all at least based on you know the pharmacokinetic studies which i mean we're relying on the drug to get into the body so it's not getting into the body what is the fucking point and then
00:36:44
Annatasha
I love listening to Bailey always try to be diplomatic and then just unraveling. Like, that's one of my favorite things where he'll be like, look, I just, you know, if there's no other option and like, you know, it could be, fuck this.
00:36:49
Gianluca Bini
Yeah.
00:36:50
Ryan Bailey
right
00:36:55
Ryan Bailey
I mean, are probably patients that we need to think about it for.
00:36:56
Annatasha
Yeah.
00:36:58
Ryan Bailey
And like, it's probably the last line and like, it's an unpredictable, it's like, like I can tell you, I had a dog growing up. He was on tramadol. The tramadol seemed to help it. This was before I knew anything about these things.
00:37:10
Ryan Bailey
And like, there are probably some patients who have an altered pathway and they do have, they make the Odesmethyl tramadol and it works for them. It's just unpredictable in dogs. Cats, everything else, they're fine.
00:37:21
Ryan Bailey
Give them, give them all the tramadol you want. It doesn't matter. but the federal patch, like it just doesn't seem to absorb because their skin is just different than humans. And so we don't get plasma concentrations.
00:37:30
Ryan Bailey
And then the ones we do, they all get fucking manic as hell. And like you tell the owner to pull the fentanyl patch off and the dog is like right as rain and everything's fine. And like, is, was that beneficial for the dog to be like screaming at home and like bothering the owners and anorexic and this and that, like that's also probably not beneficial either.
00:37:52
Gianluca Bini
I mean, feel like, know, depends on the patient, right? There are some patients that do well on it, some patients do not.
00:37:58
Ryan Bailey
Sure. Yeah.
00:38:00
Gianluca Bini
Yeah, I mean,
00:38:01
Ryan Bailey
And what I say applies to like when I, you know, obviously I'm the one who's like, well, the paper says this and it's like, I'm choosing to look at it as like a population level. I'm not thinking 5%. I'm thinking 95%. I'm thinking what are the chances of the patient front of me responding well to this medication or poorly test medication? And I'm going to take the good odds and not the like 5% odds.
00:38:23
Gianluca Bini
Fair.
00:38:23
Ryan Bailey
I'm looking for a horse, not fucking unicorn.
00:38:23
Gianluca Bini
Fair.
00:38:26
Gianluca Bini
So right in the wave of topical stuff, right? Like, what about Zorpium?
00:38:34
Ryan Bailey
I use it a fair bit in previous job. I got burned quite a few times, absolutely, for sure. Like, some of those cats got manic because cats and opioids are not always good mix.
00:38:45
Gianluca Bini
Nice. Nice.
00:38:48
Ryan Bailey
And it sucked, for sure.
00:38:52
Ryan Bailey
I used to be pretty militant about, like, no buprenorphine for cats before a surgical case because...
00:38:52
Gianluca Bini
So yeah, that's
00:39:00
Ryan Bailey
what if we want to do this or that or whatever? Like what if money is a Pyramid Wagonist? And then I totally relaxed because the evidence for cats is continuing to mount about Pyramid Wagonist not being the hot shit we like to think they are.
00:39:15
Ryan Bailey
And so I tended to be like, oh, well, the cat's got buprenorphine, like log-acting buprenorphine on board, so it will be copacetic, essentially.
00:39:23
Ryan Bailey
But there were definitely some cats that got manic. But I also think for owners, it's just such a...
00:39:31
Ryan Bailey
It's just such a gift if they don't have to like orally pill this cat.
00:39:35
Annatasha
Thank you.
00:39:36
Ryan Bailey
Cause like, let me tell you as an owner of two cats, one of them, that cat is as dumb as a rock.
00:39:36
Gianluca Bini
Yeah.
00:39:42
Ryan Bailey
And you just put the fucking chew rule out. You, I, I gave them like a massive, like, like dog-sized trazodone for him and he just like slurped that thing down like was nobody's business. Carol's like, how is gonna eat this horse pill? And I was like, don't you worry. And he just fucking took it like a champ.
00:40:01
Ryan Bailey
The other cat, if have to orally medicate her, it's like, honestly, I'd probably have to consider like, I don't know.
00:40:08
Annatasha
Anesthesia in a stomach tube.
00:40:10
Ryan Bailey
Yeah, exactly. Exactly. Cause like, it's just, there's no, like getting oral medications into Lucy is like literally hell.
00:40:18
Annatasha
I think the other thing that I also find that a lot of people like in terms of compliance can be a limiting factor is the number of oral medications and also the frequency of the dosing, right?
00:40:18
Gianluca Bini
Yeah.
00:40:27
Ryan Bailey
Absolutely.
00:40:28
Annatasha
Like, God, I mean, same thing with me. Like, first of all, the chance of me oral medicating Brownie is the chance of me launching into space and discovering a new planet. And then if I were to go home and have like four different medications and one's at 12 hours and one's at eight hours and whatever, I would never see that cat again.
00:40:46
Annatasha
That cat, I would never see that cat again.
00:40:48
Annatasha
And if I did, we would have full on scale warfare. And I'm not sure in terms of quality of life for either of us, I would be like, I need another option. Now I can... bring home needles and do my own injections type drama-rama, but most people cannot. So, you know, when they go home with one of those, you know, like those brown bags full of like 95 medications, I'm like, what do you think the odds are that they're going to actually get that done and B, finish the course of treatment? Because I just think it's so impractical.
00:41:16
Ryan Bailey
I think about that. I even see all these cats go home and all these like pill vials and I'm like, who are you fucking kidding? That cat got one pill?
00:41:25
Annatasha
And we all have like these tricks. We're like, well, I'm going to put it in butter and I'm going to mix it in tuna sauce. And I'm like, cats, you can get away with it one time.
00:41:34
Ryan Bailey
Yeah.
00:41:34
Annatasha
And then they'll be like, oh, I'm not falling for this shit again.
00:41:37
Ryan Bailey
Yeah.
00:41:38
Annatasha
Right? Like there's no way.
00:41:39
Ryan Bailey
They tried to fuck you. These fuckers tried to fucking poison me.
00:41:44
Gianluca Bini
So, okay. But on the Zorbium side, right, I think that there has been bunch of reports of cats that got overly sedated on it, right?
00:41:56
Ryan Bailey
Oh, yeah, I think that's true, too. I mean, I also had a rule of thumb.
00:41:57
Gianluca Bini
Right?
00:42:00
Ryan Bailey
Only the big Zorbium, no matter the size of the cat, and, like, because every cat to me is five pounds, and so it was all.
00:42:07
Gianluca Bini
Wait, wait, wait, wait. You will always give the...
00:42:09
Annatasha
Five pounds or five kilos.
00:42:11
Ryan Bailey
Like, five kilos, you're right, sorry. Like, because it's over six pounds was the dosing, so, like, the big cats didn't get any more.
00:42:13
Gianluca Bini
There is two sizes, right?
00:42:13
Annatasha
I would say, oh, this is one guy.
00:42:21
Gianluca Bini
Wait, let me figure this out.
00:42:21
Ryan Bailey
You know what I mean?
00:42:24
Gianluca Bini
So there's two dosing of sorbium, right?
00:42:26
Ryan Bailey
Yes.
00:42:26
Gianluca Bini
The low dose and the high
00:42:27
Ryan Bailey
Under six pounds, which is 0.4 mils or one mil, which is 20 milligrams, which I also don't understand, but I, that's like a further issue.
00:42:31
Gianluca Bini
Okay.
00:42:35
Ryan Bailey
No,
00:42:37
Gianluca Bini
So you were giving small dose to everybody.
00:42:40
Ryan Bailey
no, I gave the big dose to all adult size cats.
00:42:44
Gianluca Bini
Jesus, right. Okay, so I have clinics saying the opposite, right? They gave the small dose to everybody because they don't wanna overly sedate them, right?
00:42:50
Ryan Bailey
Yeah.
00:42:54
Ryan Bailey
Yeah.
00:42:54
Annatasha
Well, is it better to overly sedate them or underly treat them too?
00:42:54
Ryan Bailey
Yeah.
00:42:58
Annatasha
Because this is one of my pet peeves about buprenorphine in general is that people give these bullshit sub analgesic doses clinically to cats who've had major therapeutic intervention.
00:43:08
Annatasha
And I'm like, what are we trying to achieve here other than make ourselves feel better about dumb decisions?
00:43:13
Ryan Bailey
Yeah. I mean, I... Whoa.
00:43:15
Annatasha
Do you give Zorbine any...
00:43:18
Gianluca Bini
Do I give Zorbium? No, usually, know, that's not something that we... I mean, unless the clinic asks for, you know, advice.
00:43:29
Annatasha
Me either. So I'm pretty sure we're going to get some Zorbium sponsorship for the podcast.
00:43:43
Gianluca Bini
Yeah.
00:43:43
Annatasha
Medelia.
00:43:45
Ryan Bailey
do know, do know a fair number of reports about that causing a degree of sedation that was not really appreciated by anesthesiologists.
00:43:55
Ryan Bailey
And so they tended to dose down and found it to be a better balance of like sustained analgesia wall. But that one also never made sense to me because it's a deep, it's just like a big old dose. It's not a special molecule. So like,
00:44:11
Annatasha
makes for a pretty interesting podcast. But yeah, opinions. It's
00:44:15
Ryan Bailey
We haven't even touched a bunch of them.
00:44:16
Ryan Bailey
What about Acetamethin? Because that's the new thing that's sweeping the nation. It's the new old thing. It's old, but it's new again, and everyone loves it.
00:44:24
Annatasha
only new in this continent. Everybody else has been on the paracetamol like train.
00:44:29
Ryan Bailey
I get a million questions about it and I'm like, I'm unprepared to answer that because it's an institutional specific thing and I wasn't an institution specific to it. So I can't answer that question for you, unfortunately.
00:44:40
Annatasha
Yeah, it's only new in North America, right?
00:44:43
Annatasha
Like the EU, the UK, Australia, New Zealand, parts of Asia, like they've been all on top of that situation.
00:44:46
Ryan Bailey
Oh yeah.
00:44:47
Gianluca Bini
Yeah, they were using it.
00:44:51
Annatasha
So...
00:44:51
Gianluca Bini
We had injectable, they call it paracetamol, we call it acetaminophen.
00:44:56
Ryan Bailey
Yeah. Yeah.
00:44:59
Gianluca Bini
But, I mean, we had injectable all the time in England. think it's newish to us. But I mean, I think it works.
00:45:08
Annatasha
Do you think it works as standalone though, Beanie, or more as an adjunct?
00:45:08
Ryan Bailey
When are you waiting for it?
00:45:12
Annatasha
Because certainly the literature is not super fan of the efficacy of paracetamol as first line or as a standalone.
00:45:12
Gianluca Bini
I think it's jammed, you know, with other things.
00:45:18
Gianluca Bini
It's true. Yeah.
00:45:21
Annatasha
I often use it in addition to something else. But I mean, as a person who suffers from migraines, Tylenol ain't getting the job done, let me tell you.
00:45:27
Gianluca Bini
Yeah.
00:45:34
Ryan Bailey
But what about those patients who maybe you don't want to use an NSAID? Would you feel more comfortable using acetaminophen, paracetamol in those patients?
00:45:39
Annatasha
yeah
00:45:46
Gianluca Bini
Yeah.
00:45:46
Ryan Bailey
Are you worried about the same kind of risk giving it? If you work in a place where you have the injectable formulation, because like in humans, you get injectable paracetamol, I think quite commonly before major surgical procedures, if I remember correctly.
Acetaminophen and Buprenorphine Discussion
00:46:02
Ryan Bailey
And so like, yeah.
00:46:03
Gianluca Bini
I'm not worried about AKI. The risk with Tylenol or acidaminophen, it's, it's, it's more on the liver side than on the, than on the kidney side.
00:46:11
Ryan Bailey
Yeah.
00:46:13
Gianluca Bini
So in patients with liver disease, yes, I am worried about Tylenol too. Right. But, again, it depends on what kind of level of liver disease we're talking about.
00:46:22
Ryan Bailey
Right, for sure.
00:46:22
Gianluca Bini
We're talking about dysfunction or we're talking about mild elevation of liver enzymes, like who gives a fuck.
00:46:27
Ryan Bailey
Yeah.
00:46:28
Gianluca Bini
Right. But,
00:46:29
Ryan Bailey
Yeah.
00:46:30
Gianluca Bini
But I think Tylenol definitely can be used more, quote unquote, freely or with less risk than NSAIDs in some cases.
00:46:38
Ryan Bailey
Yeah.
00:46:44
Ryan Bailey
As long as you're not a cat.
00:46:47
Gianluca Bini
Correct, not that.
00:46:47
Annatasha
I knew you were going to say that.
00:46:49
Ryan Bailey
I mean, we should just clarify for the people who don't have lemon-jones open front of them and don't remember everything about acetaminophen that is not for use in cats.
00:46:52
Gianluca Bini
No, that's fair.
00:46:53
Annatasha
It's the dog thing.
00:46:58
Gianluca Bini
That is fair. That is.
00:47:00
Ryan Bailey
Isn't that a methemoglobinemia drug for them?
00:47:04
Gianluca Bini
Yeah.
00:47:04
Annatasha
Well, there's a P45 cytochrome limitation that will, yeah, that then drives up your plasma concentration and that's what perpetuates the toxicity. Okay, that's fine.
00:47:12
Gianluca Bini
Correct.
00:47:13
Annatasha
That's fine. don't care. Yeah, we'll shut
00:47:20
Gianluca Bini
What about Amanda then?
00:47:27
Ryan Bailey
Did I use it? It was always in my arsenal. So let me tell you, I had a pain clinic. I saw maybe 10 patients. The majority of them were osteosarcts.
00:47:35
Gianluca Bini
Will go in your lifetime or a day?
00:47:38
Ryan Bailey
In like the time I was in the job, like that was the amount of patients. And it was almost all osteosarcoma patients who didn't want amputate, who had seen the surgeon, who then referred them to see me to talk about pain management. And the first step for me was unravel their like pain medication history and talk to them about like,
00:47:58
Ryan Bailey
what viewed as a entry level pain management plan to start this patient on so we could get like some good baseline information about what works and what doesn't work before we start throwing the kitchen sink and the owner has a thousand fucking pills to give the dog.
00:48:16
Ryan Bailey
Yeah. So I, it was always mentioned as like, think I chose a mantidine was often a second line drug for Most of it was like, well, let's get you on like a regular non-steroidal anti-inflammatory drug.
00:48:17
Annatasha
Yeah.
00:48:28
Ryan Bailey
And let's talk about how we're going to utilize opioids. And then brief discussion. So I will say did in those patients, given the type of disease process they had, I did recommend gabapentin, but also did add the caveat that like it can be hit or miss.
00:48:45
Ryan Bailey
And some patients absolutely love it. Some patients absolutely hate it, which I also learned when I was at the human pain clinic. Some people think gabapentin actually changed their life. And some people are like, this is the worst drug I've ever been on.
00:48:56
Ryan Bailey
And I never want to take another pill because I feel like I'm in a fog. So that's where I started personally.
00:49:03
Gianluca Bini
So, Amanda then, as an agent, probably okay, not first line. Okay.
00:49:09
Ryan Bailey
Yeah. And the evidence for amantadine that's stronger, I think, was amantadine combined with an NSAID for pain.
00:49:10
Gianluca Bini
How about oral?
00:49:17
Gianluca Bini
Got
00:49:18
Ryan Bailey
So that's...
00:49:19
Annatasha
I think you should get though, which is like something important too, like your first dose of amantadine is unlikely to really have any analgesic efficacy, right?
00:49:26
Ryan Bailey
Yeah, absolutely.
00:49:28
Ryan Bailey
Absolutely.
00:49:28
Annatasha
Also true of gabapentin, right?
00:49:29
Gianluca Bini
Cheers, Abuelo.
00:49:31
Ryan Bailey
Yes.
00:49:35
Annatasha
I think, you know, building to effective plasma concentration for your analgesic threshold is an important consideration. So you can't just jump the gun with imantadine. I happen to like imantadine very much as a chronicity, as an adjunct. And I really sort of push...
00:49:53
Annatasha
The dosing label limits as well, like, you know, it's supposed to be three five mg per kg per day once a day, but, you know, there's some more evidence coming out that if you do it twice a day, like Q12, and, like, you can go up on the dose, and, like, I will edge them up, particularly for in that specific instance where if you have, like, multifactorial complex neoplastic pain, and it's really, at this question, it's 100% palliative, then I really don't give two shits about that dosing, right?
00:50:19
Ryan Bailey
Right. Yeah. Right, right.
00:50:20
Annatasha
So... The safety margin for the NMDA receptor antagonist is enormous, which is why I feel comfortable in doing so, just so our listeners understand that.
00:50:22
Ryan Bailey
Yeah.
00:50:32
Gianluca Bini
So how about oral buprenorphine?
00:50:36
Annatasha
In which species?
00:50:36
Ryan Bailey
Well, I would be a miss if I didn't mention that the papers in which it was originally described were given oral transmucosal and then sampling the jugular vein.
00:50:38
Gianluca Bini
Pots and dogs.
00:50:52
Ryan Bailey
So they probably overestimated plasma concentrations to some extent.
00:50:58
Annatasha
That's a very interesting insight.
00:50:59
Gianluca Bini
Okay.
00:51:00
Annatasha
I like that.
00:51:01
Gianluca Bini
That's fair.
00:51:02
Ryan Bailey
Yeah, that was shout out, shout UC Davis.
00:51:06
Ryan Bailey
Shout out Bruno Pippin.
00:51:10
Ryan Bailey
It
00:51:12
Gianluca Bini
Nice.
00:51:13
Annatasha
I mean, that's the type of nitpicky bullshit that we're accustomed to with Dr. Bailey. But no, that actually, that's a good point too, especially if it does, if it is filtering down from Bruno is like the pharmacology.
00:51:19
Gianluca Bini
Yeah,
00:51:20
Ryan Bailey
is.
00:51:24
Annatasha
Yeah.
00:51:25
Ryan Bailey
I feel like might've repeated that experiment and looked at like arterial concentrations to like get a better, you know,
00:51:25
Gianluca Bini
that's fair.
00:51:31
Ryan Bailey
like to do it right. And I think they were overestimated marginally, but I think they were still potentially therapeutic. I mean, I'll tell you, it works in my cats. Both of them. Oh, Lucy, they love the buprenorphine.
00:51:41
Gianluca Bini
I
00:51:43
Ryan Bailey
They're fiends.
00:51:44
Gianluca Bini
think it works. I mean, I think it's good...
00:51:47
Annatasha
I like buber nerfing in cats specifically.
00:51:49
Ryan Bailey
Yeah, I agree.
00:51:51
Gianluca Bini
How concerned are you, granted that, again, we usually are not the one prescribing this, but are we worried about diversion?
00:51:51
Annatasha
think it's.
00:52:03
Ryan Bailey
Absolutely. I mean, we so like, I don't know what the what the laws are like, where you all practice, but I do know some colleagues who practice on the West Coast who do have to get fairly extensive opioid histories about their owners before they can prescribe them oral opioids.
00:52:21
Annatasha
Are we talking about buprenorphine specifically?
00:52:23
Gianluca Bini
Yeah,
00:52:24
Annatasha
Oh, okay. No, I mean, buprenorphine is sometimes used in human medicine as the weaning opioid for severe addicts, right? Like if you're coming off heroin or what have you, buprenorphine can be an alternative to methadone, right?
00:52:39
Annatasha
So, yeah.
00:52:39
Gianluca Bini
no, no, that's fair. But that's I'm like, you know, I think we're worried about diversion from a legal standpoint, but I think that from a practical standpoint, it's probably...
00:52:49
Annatasha
I'm not that worried.
00:52:51
Gianluca Bini
The same with, you know, when people ask about, you know, I'm worried about keeping a schedule two in my clinic.
00:52:51
Ryan Bailey
Yeah.
00:52:59
Gianluca Bini
First off, I always tell them that, you know, doing poor analgesia, you know, the diversion is not an excuse for shitty analgesia.
00:53:03
Ryan Bailey
For sure, for sure.
00:53:11
Gianluca Bini
And, you know, the answer to diversion is a fucking camera above the lockbox. But, you know, methadone, technically, you know, what diversion do you have? Like, what do they do with it? Do they get better?
00:53:27
Gianluca Bini
Like, you know what mean? Like, how, who's going to steal methadone? You know what mean? Like, so, I don't know. I think that we are worried about it from a legal standpoint. There is a chance, but like,
00:53:38
Gianluca Bini
I think that probably we're a little bit overly worried, right?
00:53:42
Ryan Bailey
I mean, I think the other maybe little like thing to drop in here they're also dog shit for anything but acute pain management, the opioids.
00:53:56
Gianluca Bini
What do you mean?
00:54:05
Annatasha
Thank
00:54:16
Ryan Bailey
chronic opioids get and it causes them to vomit so you have clinic like you have statistically significant changes in pain scores but their lives aren't actually better and they throw up more
00:54:28
Gianluca Bini
Oh, no, no, that's fair. I'm just saying, I'm just saying, you know, the diversion for, from recreational purposes.
00:54:37
Ryan Bailey
oh I just I meant like as using opioids in our patients like short-term short course kind of thing not long-term so like You know, I think, I guess maybe where I'm coming at it from is like, they're kind of dog shit in our patients anyway, in a way.
00:54:55
Gianluca Bini
Like you're saying sending the patient home with opioids is not good.
00:55:01
Ryan Bailey
mean, I had to only choose, I had to only choose one drug to send a painful patient home on, it's not an opioid, that's for sure.
00:55:11
Gianluca Bini
Fair.
00:55:11
Ryan Bailey
was only allowed one.
00:55:13
Annatasha
which one would you pick
00:55:16
Gianluca Bini
Okay.
00:55:17
Gianluca Bini
Fair.
00:55:19
Ryan Bailey
Like when I, when I saw those pain patients, I would tell them opioids are a pulse therapy. We'll do a couple of days. If the dog has a bad day, we can do a couple of days, get them through it. And then we're stopping at cold Turkey.
00:55:30
Gianluca Bini
I think that that's how most people use it though, right? Like, you know, even when you send home a bubonorphine, you don't send them home with a fucking bottle, right?
00:55:38
Ryan Bailey
Oh yeah, for sure.
00:55:38
Gianluca Bini
You can't do like two or three doses.
00:55:39
Ryan Bailey
But like, yeah, yeah.
00:55:41
Gianluca Bini
You know what mean? Like, yeah, yeah, fair, sure.
00:55:43
Ryan Bailey
But those patients like have a chronic condition like osteosaric or osteoarthritis or whatever, you know, they like, I guess that's, that's where I'm coming at it from is like their analgesic efficacy is probably like mild to moderate in the, in the outpatient.
00:55:56
Gianluca Bini
Yeah, it's for a cupid.
00:55:59
Ryan Bailey
And then, and then on top of that in dogs, like what are our options?
00:56:04
Ryan Bailey
Like what, what are you giving a dog for an oral opioid?
00:56:09
Annatasha
tramadol
00:56:12
Ryan Bailey
I always use the paper from Butch Koukanich that was like, showed that they had pretty reasonable plasma concentrations of morphine when administered codeine because of their metabolism. So like, that I think has the strongest evidence, but I don't know if we actually have the efficacy evidence of that drug then being used, unfortunately.
00:56:32
Ryan Bailey
But getting codeine can be a real challenge for sure.
00:56:33
Gianluca Bini
Yeah. Yeah.
00:56:37
Ryan Bailey
It's like schedule two, you got to write a script for it and this and that. It does create a lot of headaches, unfortunately, for prescribers, for sure.
00:56:50
Gianluca Bini
Yeah. Well, yeah, I think we covered most of the
00:56:56
Annatasha
We didn't delve into GABA, but we've talked GABA before,
00:56:57
Ryan Bailey
We covered a lot.
Closing Thoughts and Hot Dog Anecdotes
00:56:59
Annatasha
so.
00:56:59
Annatasha
What?
00:57:00
Ryan Bailey
That's true. We didn't, we did not get to GABA of last GABA is, I mean, I mentioned it casually that some people love and some people hate it.
00:57:07
Gianluca Bini
Yeah.
00:57:08
Ryan Bailey
You what else we didn't mention? The most important part of this podcast, hot dogs. Anyone had a good hot dog recently?
00:57:15
Gianluca Bini
Well, I was, sat for three hours at fucking Costco, getting zero, but I was, had so many hot dogs around me.
00:57:19
Ryan Bailey
How many, how many hot dogs you put down?
00:57:26
Ryan Bailey
Oh my God. We've been going to Home Depot like every weekend and they got the hot dogs there and I get fix and Frank's fucking like almost every time.
00:57:34
Gianluca Bini
It's usually not the reason.
00:57:35
Ryan Bailey
Karen was like, you know what I can go for? A hot dog. We had hot dogs multiple weekends in a row. I live in the dream right now. me tell you.
00:57:43
Annatasha
Bailey, what is your Lipitor dose? Like, honestly.
00:57:49
Ryan Bailey
And summer is coming up.
00:57:51
Annatasha
dog season.
00:57:51
Ryan Bailey
It's going to be hot dog central.
00:57:54
Annatasha
I honestly think, Bailey, like, I don't know, when you turn 50 or like, I don't know, like an important wedding anniversary, like you should devise like a global hot dog tour where you go on a trip and you just hit the major hot dog spots and then like make it a show or write a book or something like.
00:58:11
Ryan Bailey
can tell you, every time I'm out, I, like, every time I go to a foreign country, I basically try and find a hot dog to eat.
00:58:19
Gianluca Bini
I see your Instagram.
00:58:19
Ryan Bailey
Because, yeah.
00:58:20
Annatasha
We're aware. are aware.
00:58:21
Ryan Bailey
Yeah.
00:58:22
Annatasha
Hmm.
00:58:23
Gianluca Bini
I see your Instagram stories.
00:58:25
Ryan Bailey
Get ready. Get ready.
00:58:28
Gianluca Bini
Oh my God. All right. Well, this was a good chat guys. was cool.
00:58:34
Ryan Bailey
Yeah, I think it was. Hopefully someone can take something away from it other than like, we hate all the oral options we have available to us.
00:58:42
Gianluca Bini
I don't think that that's what we say at all.
00:58:44
Ryan Bailey
Yeah. Yeah.
00:58:46
Annatasha
It's challenging. Don't get me wrong. And it's really challenging too, if there's some sort of clinical preclusion for the NSAID, because that's really like, I think we're the three of us all tend to start.
00:58:48
Ryan Bailey
Yeah, for sure.
00:58:56
Ryan Bailey
Yeah.
00:58:57
Gianluca Bini
That
00:58:57
Ryan Bailey
That's...
00:59:08
Annatasha
But yeah, I mean, it is hard and we didn't get to grab a parent, for example, like we didn't,
00:59:13
Ryan Bailey
Oh, yeah.
00:59:14
Annatasha
We didn't have a chance.
00:59:15
Ryan Bailey
Well, I'm coming up again.
00:59:18
Annatasha
Yeah.
00:59:19
Annatasha
And actually there was something earlier that you said, and I was like, that's my next topic. Like right there is going to be that.
00:59:25
Ryan Bailey
what was it?
00:59:26
Annatasha
I can't tell you. Then it's not a random anesthesia topic.
00:59:27
Ryan Bailey
God damn
00:59:28
Annatasha
Then it's, then it's a premeditated anesthesia topic, which ruins all of our branding guys. Like, yeah. So I can't tell you, but I was
00:59:36
Ryan Bailey
I thought I'd be raining with hot dogs. Am I wrong? Fuck.
00:59:40
Annatasha
The random hot dog podcast. It's basically getting to that at the point.
00:59:42
Gianluca Bini
There you go.
00:59:45
Annatasha
But yeah, no, I can't tell you, but I was totally like, oh yeah, that's what I want to talk about next time.
00:59:49
Ryan Bailey
Fuck.
00:59:50
Gianluca Bini
I got a good topic too. I'm just brewing it. All right. You guys have a good night.
00:59:58
Annatasha
Thanks guys.
00:59:58
Ryan Bailey
Bye.
00:59:58
Gianluca Bini
guys.